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The recent growth of medicine sales online represents a major disruption to pharmacy markets, with COVID-19 encouraging this trend further. While e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in low-income and middle-income countries (LMICs). Public health concerns associated with e-pharmacy include the sale of prescription-only medicines without a prescription and the sale of substandard and falsified medicines. There are also non-health-related risks such as consumer fraud and lack of data privacy. However, e-pharmacy may also have the potential to improve access to medicines. Drawing on existing literature and a set of key informant interviews in Kenya, Nigeria and India, we examine the e-pharmacy regulatory systems in LMICs. None of the study countries had yet enacted a regulatory framework specific to e-pharmacy. Key regulatory challenges included the lack of consensus on regulatory models, lack of regulatory capacity, regulating sales across borders and risks of over-regulation. However, e-pharmacy also presents opportunities to enhance medicine regulation—through consolidation in the sector, and the traceability and transparency that online records offer. The regulatory process needs to be adapted to keep pace with this dynamic landscape and exploit these possibilities. This will require exploration of a range of innovative regulatory options, collaboration with larger, more compliant businesses, and engagement with global regulatory bodies. A key first step must be ensuring that national regulators are equipped with the necessary awareness and technical expertise to actively oversee this e-pharmacy activity.

The English National Health Service (NHS) constitutes a unique institutional context, which combines elements of hierarchy, markets and networks. This has always raised issues about competing forms of accountability. Recent policy has emphasised a move from quasi market competition towards collaboration in the form of new regional organisational arrangements known as Sustainability and Transformation Partnerships (STPs). We explore accountability relationships in STPs, focusing on the challenges of increasing horizontal accountability given existing vertical accountabilities, most notably to national regulators. We utilize a case study approach concentrated on three Clinical Commissioning Groups (CCGs) in urban and rural settings in England. We conducted in-person interviews with 22 managers from NHS organisations and local authorities and examined local documents to obtain information on governance and accountability structures. The fieldwork was undertaken between November 2017 and July 2018. We analysed results by considering which actors were accountable to what forums and the nature of the obligation (vertical or horizontal). We found that individual organisations still retained vertical accountabilities and were reluctant to be held accountable for the whole STP, given they were responsible for only part of the joint effort. Moreover, organisations did not feel accountable to STPs and instead highlighted vertical accountabilities upwards to their own boards and to national regulators; and downwards to the public. But while local commissioning organisations, CCGs engaged with their members and the public, STPs failed to engage adequately with the public. Nevertheless, there were indications that horizontal accountability was starting to develop. This could become complementary to vertical accountability by facilitating mutual learning and peer review to anticipate and defer regulatory intervention. While vertical accountability is necessary to provide oversight and apply sanctions, it is not sufficient and should be accompanied by horizontal accountability.

COVID-19 has thrown NHS procurement into the limelight, but the shortage of personal protective equipment (PPE) has complex origins. This article explores the long-lasting struggle for centralisation in NHS procurement and its impact on the current PPE crisis.

Chapter 7 reports two aspects of research on contracting in the NHS. The first investigates how the policies to use contractual mechanisms including financial risk allocation work in practice. Most of the contractual relationships between NHS owned acute providers and commissioners were characterised by the use of general annual financial settlements outside the terms of the contract. This behaviour appeared to be increasing over time. The second study comprises a review of the evidence concerning new forms of contract being introduced into the NHS: alliance and outcome based contracts. These are aimed at facilitating the integration of services and improving quality of care. Evidence from other sectors indicates that new models of contracting may result in cost savings including a reduction in capital costs, the development of innovations and benefits in relation to time. But there are high transaction costs in relation to the process of contract negotiation and specification. The evidence base regarding improvements in the quality of services is not convincing. These models carry a number of potential governance issues in relation to their implementation in the NHS, and are at risk of failing to satisfy public sector governance objectives including accountability, integrity and transparency.

The coordination of public services is an enduring challenge and an important policy priority. One way to achieve collaboration across organizational boundaries, which is being considered in public services such as the English National Health Service (NHS), is through the adoption of alliance contracting, prime provider contracting and outcome-based contracting. This article reviews the cross-sectoral literature concerning the characteristics of these new contractual models, how they function, their impact, and their relation to public sector governance objectives. These new contractual forms are characterized as models which, in line with the New Public Management (NPM)/post-NPM agenda, seek to incentivize providers through the transfer of risk from the commissioners to the providers of services. Key findings are that the models are likely to incur high transaction costs relating to the negotiation and specification of outcomes and rely heavily on the relational aspects of contracting. There is also found to be a lack of convincing cross-sectoral evidence of the impact of the models, particularly in relation to improving coordination across organizations. The article questions the reconciliation of the use of these new contractual models in settings such as the English NHS with the requirements of public sector governance for transparency and accountability. The models serve to highlight the problems inherent in the NPM/post-NPM agenda of the transfer of risk away from commissioners of services in terms of transparency and accountability.

Since 1990, market mechanisms have occurred in the predominantly hierarchical National Health Service (NHS). The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared with politicians (known as ‘juridification’). To assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.

Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers' views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers' understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.

A challenge facing health systems such as the English National Health Service (NHS), which operate in a context of diversity of provision and scarcity of financial resources, is how organisations engaged in the provision of services can be encouraged to adopt collective resource utilisation strategies to ensure limited resources are utilised in the interests of service users and, in the case of tax funded services, the general public. In this paper the authors apply Elinor Ostrom's work concerning communities' self-governance of common pool resources to the development of collective approaches to the utilisation of resources for the provision of health services. Focusing on the establishment of Sustainability and Transformation Partnerships (STPs) in the English NHS, and drawing on interviews with senior managers in English NHS purchaser and provider organisations, we use Ostrom's work as a frame to analyse STPs, as vehicles to agree and enact shared rules governing the allocation of financial resources, and the role of the state in relation to the development of this collective governance. While there was an unwillingness to use STPs to agree collective rules for resource allocation, we found that local actors were discussing and agreeing collective approaches regarding how resources should be utilised to deliver health services in order to make best use of scarce resources. State influence on the development of collective approaches to resource allocation through the STP was viewed by some as coercive, but also provided a necessary function to ensure accountability. Our analysis suggests Ostrom's notion of resource 'appropriation' should be extended to capture the nuances of resource utilisation in complex production chains, such as those involved in the delivery of health services where the extraction of funds is not an end in itself, but where the value of resources depends on how they are utilised.

This article examines the impact of the Health and Social Care Act 2012 on the regulation of competition in the English National Health Service (NHS), by focussing on the change it marked from a system of sector-specific regulation to one which is clearly based in competition law. It has been suggested that the Act and its associated reforms would significantly alter accountability in the NHS, and would change decisions from the remit of public policy to that of the law. To assess the impact the Act has had in practice, the article compares the interpretation of the rules regarding competition in the NHS by the regulators of competition immediately before, and following, the passing of the Act. It argues that, whilst the reforms have the potential significantly to alter the way competition in the NHS is regulated, the impact of the reforms in this area is limited by the development of systems within the NHS to manage and resolve issues internally where possible.

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK-wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro-level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.

In this paper attempts are made to trace the ways in which climates were shown on maps of the world beginning with the Greek philosopher Pythagoras and ending with Koeppen. Much of the information was obtained by examining original maps in the Clements Library of the University of Michigan. It is concluded that the most-used climate classification of climates today, that of Koeppen, derives from the five climate zones of the ancient Greeks and that the world is ready for a new classification.

Objectives To examine the types of choices available to patients in the English NHS when being referred for acute hospital care in the light of the divergence of patient choice policy in the four countries of the UK. Methods Case studies of eight local health economies in England, Scotland, Northern Ireland and Wales (two in each country); 125 semi-structured interviews with staff in acute services providers, purchasers and general practitioners (GPs). Results GPs and providers in England both had a clear understanding of the choice of provider policy and the right of patients to choose a provider. Other referral choices potentially available to patients in all four countries were date and time of appointment, site and specialist. In practice, the availability of these choices differed between and within countries and was shaped by factors beyond choice policy, such as the number of providers in an area. There were similarities between the four countries in the way choices were offered to patients, namely lack of clarity about the options available, limited discussion of choices between referrers and patients, and tension between offering choice and managing waiting lists. Conclusions There are challenges in implementing pro-choice policy in health care systems where it has not traditionally existed. Differences between England and the other countries of the UK were limited in the way choice was offered to patients. A cultural shift is needed to ensure that patients are fully informed by GPs of the choices available to them.

This paper presents the results of two research projects: one on the impact of climate change on shipping and hydro power generation in the Great Lakes, and one on the impact of climate change on water resources in the Grand River basin in Ontario. Conclusions from the first study indicate that under climate change, the average annual costs to Canadian Great Lakes shipping companies would increase by 30% and that hydro generating stations on the Great Lakes would lose significant generating power. The Grand River study indicates that with climate change and higher temperatures, the annual loss of water to the atmosphere through evapotranspiration would increase from 15 to 18% resulting in a decline in river flows of 20 to 39% and an increase in water deficiency (drought) of 15 to 36%.

A university-based water institute can play a vital role in the research into and management of Canada’s water resources. It can draw upon the expertise of academics in many disciplines and it is imperative that water research be multi-disciplinary in nature. It is an added advantage if the institute has members from several universities, since often not all the expertise necessary to solve water problems is available at one university. In a university setting, a multi-disciplinary education can be provided to future aquatic scientists and managers.Also, in a university setting, water workshops and conferences involving government agencies and local citizens groups can be held in a non-adversarial environment. Case studies from The Great Lakes Institute (University of Windsor) and The Water Network (Universities of Waterloo, Guelph, Wilfrid Laurier and Western Ontario) will be cited.

This paper represents an attempt to combine the output of several models that deal with future climatic, hydrologic and economic conditions in the Great Lakes and makes some predictions about the possible impact of one scenario of 2 × CO2 climate on Great Lakes shipping. It is realized that there is a great deal of uncertainty in all the models and that improvements are continually being made. Data from a General Circulation Model of future temperature and precipitation in the Great Lakes basin, a Great Lakes levels and flows model from the Canada Centre for Inland Waters and an International Joint Commision's Great Lakes economic model modified by the University of Wisconsin were used. The 1900–1976 period of lake levels and flows was used. The hydrologic model indicated that future mean lake levels may be reduced by one-half meter, and that the extreme low levels of the mid 1960's could occur 77% of the time in the future. No ice cover is predicted for any lake except Erie, permitting an eleven month shipping season. Five scenarios of future impact on shipping were evaluated. It was found that mean annual shipping costs may increase by 30% and the frequency of years when costs exceed those of the period of low lake levels (1963–65) could rise to 97%. Possible policy options in a future with climatically induced lower lake levels could include regulation to keep levels artificially high by diversions into the system, or increased dredging of the connecting channels.

A high correlation exists between monthly population-weighted heating degree days (below 18C) and the use of natural gas per household for residential heating in Alberta for the period 1962–80. The use of natural gas for residential heating per household declines since 1973 following a sharp increase in gas prices.

The research reported here forms part of a large multidisciplinary study of four toxic contaminants — lead, cadmium, PCBs, and octachlorostyrene in the Essex region of southwestern Ontario. The purpose of this part of the project is to quantify the atmospheric loading of the metallic contaminants. A bulk precipitation sampler, wet-only precipitation sampler, and recording rain gauge were installed at an urban and rural site. Results from 2 years of data indicate that atmospheric loading of lead is 40–50 times that of cadmium in the city and 16–40 times that of cadmium in the rural areas. Lead loadings in the city were found to be 2–4 times higher than in the rural areas, while cadmium loadings appeared to be similar in both areas. Concentrations of the metals are higher in winter than in summer, but because of higher summer precipitation surface loadings are similar in both seasons. Preliminary statistical analysis indicates that concentrations of the metals are related to intensity and amount of precipitation but not usually to wind direction.

Bangladesh, with its small but rich agricultural land (total area 9 million ha) and large population (80 million) is faced with an acute food crisis. The economy of Bangladesh is dependent mainly upon agriculture which, in turn, is dependent upon rainfall. An increase in crop acreage and productivity during the pre-monsoon season, March to May, offers a partial solution to the problem. The water available from the rainfall of this season could be utilized through proper planning for better agricultural uses. The present study is an attempt at an inventory of such pre-monsoon rainfall, both monthly and seasonally, and its variability over time and space. The technique employed is that of trend surface mapping.

Although climate is often defined as "average weather," and most climatic maps show average conditions, there is also a need for maps showing the probabilities of various climatic events. Southern Ontario is an important agricultural area, and precipitation during the growing season an important climatic parameter. The present study examines and maps precipitation probabilities during this season in Southern Ontario. Monthly precipitation is first shown to have a normal distribution. Thus the standard deviation can be used to obtain the area under the curve that expresses the top 10% of the distribution, and also the lower 10% of the distribution. Pairs of maps are drawn for each month; one showing the precipitation amounts not exceeded in 9 yr in 10, the other showing the areas where "precipitation will not be less than" the amounts shown in 9 yr in 10. Such maps provide useful information for the agriculturist and the applied geographer as well as the layman.

Most recent research in urban precipitation has suggested that the presence of the city itself causes increased precipitation. The present paper presents the results of five years of precipitation measurement from an international network of raingages in Windsor-Detroit. Increased precipitation downwind appeared to be the case only in summer. The number of precipitation days and the number of heavy precipitation days were greatest in the southwest urban area and decreased downwind.

Monthly samples of precipitation during the period June 1975 to June 1977 from bulk type precipitation gauges located in six watersheds in southern Ontario were analyzed for sulphate, nitrogen, phosphate, chloride, calcium, sodium, potassium, magnesium, heavy metals, and PCBs. The relationship between the surface loading of the pollutant and the amount of precipitation during the observation period was investigated and a significant relationship at the .05 level was found for all pollutants except sodium. The loadings in g/ha/d were tested statistically for spatial and temporal variability. All parameter loadings showed a downward trend over time and it was suggested that this is due to decreased precipitation during the second year of observation. No significant seasonal differences were found in the surface loadings. Analysis of variance tests indicated that at the .05 level of significance, no significant differences in monthly loadings were observed for all parameters except calcium and magnesium, although some locations were very near and others hundreds of kilometers distant from the major sources of industrial pollutants.

A study of variability of runoff in the Lake Ontario basin is undertaken to provide background information for the International Field Year on the Great Lakes to be held in 1972 on Lake Ontario, since it is realized that a period of 1 year is a small sample in the life history of a lake basin and that there are large annual fluctuations in the variables in the water balance. Because of a lack of long-term records of measured runoff, the Thornthwaite-Mather water balance model for estimating point runoff from climatic data is used for the 81 stations in and near the basin with records of 15–136 years. Statistical tests show that annual station runoff has a normal distribution, and standard deviations are computed to express variability. Maps of average runoff, as well as plus and minus two standard deviations of runoff, are drawn and thus permit the estimation of the volumes of annual runoff that can be expected in the Lake Ontario basin. A coefficient of variability of runoff map indicates that the southwestern areas of the basin have the most variable runoff.

In the present study, a beginning is made into the investigation of the effect of the urban area on the microclimate of Detroit-Windsor. Diurnal and seasonal urban-rural temperature differences were investigated using three-hourly temperature data for a 10-year period for City, Metropolitan and Windsor airports. Maximum differences were observed in early morning hours and minimum or zero differences at midday. Seasonally, maximum differences were observed in August–October and minimum differences in January–March. The differences between urban and rural atmospheric transmissivity ratios were investigated for clear winter days using a Kipp and Zonen pyranometer and a model to predict incoming solar radiation at the top of the atmosphere. Urban ratios averaged 9% less, and under calm conditions, reached 25% less than in adjacent rural areas. Data from the South Eastern Michigan Council of Governments precipitation network in the Detroit area were used in a comparison with regional seasonal precipit...

An experiment to measure the daily potential evapotranspiration from vegetation-covered soil surfaces was conducted in Toronto during the 1947, 1948, and 1949 growing seasons. The potential evaporation from moist bare soil was also measured and compared with the evaporation from dry soil. Results indicate that the Thornthwaite formula for computing potential water loss is valid at this latitude for both vegetation-covered and moist soil. When drying of the surface soil occurred, the water loss was diminished.

Methods of measuring precipitation vary from country to country. Consequently, the comparability of precipitation data along international borders is questionable. The present paper compares 5 years of precipitation data at Windsor, Ontario, using the standard Canadian and United States methods of measuring precipitation. Monthly rain amounts are very similar, but substantial differences exist in snow measurement. The Canadian method appears to overestimate precipitation from snowfall.

A method of obtaining daily values of the potential evaporating power of the atmosphere was used for the first time in Canada in 1947. The results verify Thornthwaite's formula for computing potential evapotranspiration in southern Ontario. The correlation between average runoff and computed water surplus for several watersheds in Ontario and Quebec is presented on a map.

in English history."1 She could also be called the first English geographer, for she wrote the first textbook in physical geography in the English language. Her "Physical Geography"2 was published in 1848, three years after the first volume of von Humboldt's "Cosmos"3 appeared and before geography was recognized as a university discipline in Great Britain.4 Her remarkable life spanned almost a century, from 1780 to 1872. It was an exciting century for physical science, for great strides were made in astronomy, in geology, in meteorology, and in geography. Many of the great pioneers in these fields John Herschel, Charles Lyell, Roderick Murchison, and Alexander von Humboldt were her friends, and they accepted her as a fellow scientist and acknowledged her contributions to science. Yet it was also an age when women were not given a formal education. Mrs. Somerville was completely self-taught, which makes her four books in various fields of science all the more remarkable. Her

A CORDING to popular concept, the northern regions ot North America and Eurasia are differentiated areally into a series of latitudinal belts of climate, vegetation, and soils. Long before adequate observations were available, vegetation and climate were mapped by extrapolation from northern Europe eastward across Siberia and westward across North America. Bordering the Arctic Sea is the tundra; to the south of this are two concentric coniferous-forest belts, the northern and southern subArctic forest. Soil maps came later; but since observations of the soils were largely lacking, recourse was had to the familiar maps of climate and vegetation, and belts of muskeg and podsol were fitted in. However, there is growing evidence, at least in northern Canada, that the actual distribution of climate, vegetation, and soil is quite different from that concept. Recent observation and experiment in the Northwest Territories and the northern parts of the Prairie Provinces indicate that the climate is not humid, the vegetation is not forest, and the soil is not podsol.